Aircraft Accident

Investigation Bureau

Incident Final Report

Islamic Republic of IRAN

Civil Aviation Organization

State File Number: I13940227EPMNI

Type of Occurrence: Incident

Date of Occurrence: 17 May 2015

Place of Occurrence: Republic of Armenia

Aircraft Type: A300B4-600

Registration: EP-MNI

Operator: MahanAir

Date of Issue: 15 July 2016

0

Islamic Republic Of Iran

Civil Aviation Organization

Aircraft Accident Investigation Bureau

Final Report

Basic Information

State File Number: I13940227EPMNI

Type of occurrence: Incident

Date of occurrence: 17 May 2015

Place of occurrence: "Zvartnots" International Airport (UDYZ) .Republic of Armenia

Aircraft Model: A-300B4-603

Registration: EP-MNI

Operator: Mahan Air

Date of Issue : 11 Apr 2016

Civil Aviation Organization of I.R. of Iran

Aircraft Accident Investigation Department

Mehrabad International Airport

Tehran/Iran

PBO: 13445-1795

Fax: + 98 21 6601 8659

Tel.: + 98 21 6604 7965

-------------------------------------------------------------------------------------------------------

http://www.cao.ir E-mail: AIG@cao. Investigator in Charge: Hassan Rezaeifar

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Contents: Page:

Foreword--------------------------------------------------------------------------------2

Abbreviations---------------------------------------------------------------------------3

Synopsis----------------------------------------------------------------------------------4

1. Factual Information

1.1 History of Flight--------------------------------------------------------------------5

1.2 Injuries to Persons------------------------------------------------------------------5

1.3 Damage to Aircraft-----------------------------------------------------------------5

1.4 Other Damage-----------------------------------------------------------------------5

1.5 Personnel Information--------------------------------------------------------------6

1.6 Aircraft Information----------------------------------------------------------------6

1.7 Meteorological Information-------------------------------------------------------7

1.8 Aids to Navigation------------------------------------------------------------------7

1.9 Communications--------------------------------------------------------------------7

1.10 Airport Information---------------------------------------------------------------8

1.11 Flight Recorders------------------------------------------------------------------10

1.12 Wreckage and Impact Information---------------------------------------------13

1.13 Medical and Pathological Information----------------------------------------13

1.14 Fire---------------------------------------------------------------------------------13

1.15 Survival Aspects-----------------------------------------------------------------13

1.16 Tests and Research--------------------------------------------------------------13

1.17 Organizational and Management Information-------------------------------14

1.18 Additional Information----------------------------------------------------------14

1.19 Useful or Effective Investigation Techniques--------------------------------14

2. Analysis------------------------------------------------------------------------------14

3. Conclusions-------------------------------------------------------------------------16

3.1 Findings-----------------------------------------------------------------------------16

3.2 main Cause-------------------------------------------------------------------------16

3.3 contributive factors----------------------------------------------------------------16

4. Safety Recommendations---------------------------------------------------------16

2

Foreword:

According to Aircraft Accident Investigation Act of Civil Aviation

Organization of the Islamic Republic of Iran,

Accident investigation shall be conducted separately from any judicial, administrative

disposition, administrative lawsuit proceedings associated with civil or criminal

liability.

On the basis on Annex 13 to the Convention on International Civil Aviation

Organization , Chapter 3, Paragraph 3.1, and Chapter 5, Paragraph 5.4.1; it is

stipulated and recommended as follows;

The sole objective of the investigation of an incident or accident shall be the

prevention of incidents and accidents. It is not the purpose of this activity to apportion

blame or liability.

Any judicial or administrative proceedings to apportion blame or liability should be

separated from any investigation conducted under the provisions of this Annex.

3

Abbreviations: A/C Aircraft

ACC Area Control Center

ALT Altitude

AP Autopilot

APP Approach

ATIS Automatic Terminal Information Service

BEA Bureau d’Enquête et d’Analyses pour la sécurité de l’aviation civile

CAO Civil Aviation Organization

CAS Calibrated airspeed

CB Circuit Breaker

CMD Command

CVR Cockpit Voice Recorder

EGPWS Enhanced Ground Proximity Warning System

ENG Engine

FAF Final Approach Fix

FDM Flight Data Monitoring

FDR Flight data recorder

FIR Flight Information Region

FL Flight level

FO First Officer

FT Feet

GMT Greenwich Meridian Time

GW Gross Weight

IAS Indicated airspeed

ILS Instrument Landing System

LAT Latitude

LONG longitude

MEL Minimum Equipment List

MLG Main Landing Gear

NAV Navigation

NLG Nose Landing Gear

PIC Pilot in Command

PF Pilot Flying

PNF Pilot non Flying

QRH Quick Reference Handbook

R.ALT Radio Altimeter

RDR Radar

RWY Runway

TWR Tower

VIS Visibility

4

Synopsis:

On Sunday, 17.05.2015, the Accident Investigation Department of Civil Aviation

Organization of I.R of Iran was notified that an A300, EP-MNI, operated by Mahan Air with

flight No; IRM.1150 from the Imam Khomeini International airport (OIIE) to the Zvartnots

International Airport (UDYZ) /Republic of Armenia involved an incident which landed

before displaced threshold on RWY09 in Zvartnots airport.

The General department of Civil Aviation at the Government of Republic of Armenia has

initiated the investigation and According to Annex 13, chapter 5, the Notification was sent to

the State of Registry& Operator (Aircraft Accident Investigation Department of I.R of Iran

Civil Aviation Organization) and the State of Design &Manufacture (French Aircraft

Accident Investigation Bureau-BEA). Due to request of the State of Occurrence, the

investigation was delegated to the state of Registry .so The BEA Accredited Representative

and his Adviser were introduced to I.R of Iran CAO.

The Flight Data Recorder and Cockpit Voice Recorder have removed from the aircraft.

The download of the FDR had performed in Mahan Air laboratory in Imam Khomeini airport

and CVR was read out in the Iran Aseman Airline laboratory with attendance of Investigation

Team. The State of Manufacturer (BEA) has been provided the information of FDR by

investigation team too.

The Main cause of the incident was” incorrect reorganization of Threshold lights by the pilot”

so aircraft had landed after temporary approach light just before the threshold.

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1. FACTUAL INFORMATION:

1.1 History of the flight:

On MAY 17th, 2015, at 04:27 GMT, the aircraft A306 belonged to the Mahan Air took off

from IKA (IMAM KHOMEINI) airport destination to EVN (Yerevan) as a scheduled flight.

On this flight the pilot-in-command on left cockpit seat was the Pilot Flying (PF). According

to the flight plan, aircraft climbed to FL340 via flight plan route and exit from Tehran FIR via

FIR boundary MAGRI at 05:13:49 GMT.

Subsequently at 05:15:21 GMT, the Yerevan ACC controller informed the pilot about radar

vectoring for VOR/DME RWY09 for the approach and acknowledged by the pilot.

Meanwhile following the pilot request about the serviceability of ILS, the controller advised

that: "ILS Unserviceable".

At 05:19:22 aircraft commenced her descent to FL160 and delivered to the approach

controller for further descend. When the aircraft was under the control of APP RDR unit,

according NOTAM A001/15 the pilot was informed of the displacement of threshold RWY09

by 1450m to the aerodrome reference point by APP controller.

Then, At 05:36:07, the flight was cleared to descend to 5100ft for VOR/DME for RWY09.

AT 05:40:55 about 6 miles on final, the flight was cleared to land by the tower controller.

At 05:42, the pilot was advised by TWR controller that A/C is well below and the flight

replied that we are approaching visual with sign of new threshold insight.

Again at 05:42, the TWR controller advised the flight to stop descend and acknowledged by

the flight. Finally at 05:44 after landing, the A/C vacated the RWY via taxiway C.

Visual inspection by aerodrome safety personnel has indicated that the A/C landed before

displaced threshold and aircraft main wheels have collided with RWY thresholds lights

during landing on the ground.

1.2 Injuries to persons:

According to the information provided by the airline, 16 crew and 195 passengers were on

board. No injuries were reported.

1.3 Damage to aircraft:

Some minor damages to the main wheels of the aircraft were detected.

1.4 Other Damages:

Two elevated approach lights were damaged by the wheels of the aircraft.

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1.5 Personnel Information:

1.5.1 Pilot Flying :( Left Hand Seat)

- Pilot in command

- Male, 58 years old, Iranian Nationality

- Commercial pilot, ATPL (A) No.634 Class 1, from Iran CAO

- Type rating: A300-600

- Valid Medical Certification

- Total flight time: 21500 H

- Flight time on type: 4800 H

1.5.2 Pilot Non Flying: (Right Hand Seat)

- First Officer

- Male, 34 years old, Iranian Nationality

- Commercial pilot, CPL (A) No.3205 Class 2, from Iran CAO

- Type rating: A300-600

- Valid Medical Certification

- Total flight time: 2200 H

- Flight time on type: 900 H

1.6 Aircraft information:

The Airbus A300B4-603, S/N; 408 aircraft with registration EP-MNI was manufactured in

1987. It had Airworthiness Certificate No; 863104, valid until 01 Sep 2017 and issued by I.R.I

Civil Aviation Organization. A review of recent records of the aircraft did not show any

significant related malfunctions.

According to QRH of this type aircraft with mass 130 kt, the 2260 m length is required for

landing on the dry RWY with selection of low auto brake with 40 degree flap configuration.

The length of the RWY 09 was suitable for safe landing of this aircraft at the time of incident.

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1.7 Meteorological Information:

METAR at 05:30 GMT

Variable 2 m/s VIS 10 km or more Temp. +13 D.P. 10 QNH. 1018 hpa

The meteorological conditions recorded in ATC communication upon landing time were:

Wind calm. CAVOK and QNH1018

1.8 Aids to Navigation:

According NOTAM A0011/15, ILS & PAPAI for RWY 09 in Zvartnots International Airport

(UDYZ) was out of service.

1.9 Communications:

No technical communication problems reported by the flight crew. Also whole transcript of

recorded communication of the air traffic control units were delivered to IRI CAO

Investigator in charge and used for the incident analysis.

8

1.10 Airport Information:

UDYZ/EVN ZVARTNOTS International Airport is Just 12 km from the center of the capital

of Armenia-Yerevan.

ICAO IATA AIRPORT NAME CITY COUNTRY (STATE/PROVINCE)

UDYZ EVN Zvartnots International Yerevan Armenia

elevation: 2,838' (865m) location: N40 8.84 E044 23.75

ATIS 119.5

Yerevan Approach 126.0 124.0

Yerevan Ground 119.0

Yerevan Tower 128.0 124.0

Runway Dimension ILS note

09 - 27 3850m x 56m yes Asphalt

At the time of incident the available RWY Length was 2400m (3850 meters excluding

Displaced Threshold 1450m). The related issued NOTAM is:

(A0011/15 NOTAMN Q) UDDD/QFAXX/IV/NBO/A/000/999/4009N04424E005 A) UDYZ B) 1505040930 C) 1506300800 E) A/P YEREVAN (UDYZ) THRESHOLD RWY 09 REPLACED TO THE CENTER OF THE RWY BY 1450M. AT THAT TIME ILS AND PAPI FOR RWY 09 OUT OF SERVICE. SIMPL APPROACH LIGHTING SYSTEMS WILL BE AVAILABLE (SINGLE SOURCE) FOR RWY 09 ACCORDING TO FIGUER A-7, ANNEX 14 ICAO. AT THAT TIME 180 DEGREE TURN OF THE AIRCRAFT ON THE RWY 09/27 IS APPROVED FOR TAKE OFF RWY 09 AND LANDING RWY 27. FOR RWY 09 TORA (M)-2400, TODA (M)-2800, ASDA (M)-2400, LDA (M)-2400 FOR RWY 27 TORA (M)-2400, TODA (M)-2850, ASDA (M)-2400, LDA (M)-2400 CAT 1 AND 2 OUT OF SERVICE.)

(A0014/15 NOTAMN Q) UDDD/QPICH/I/NBO/A/000/999/4009N 04424E005 A) UDYZ B) 1505040930 C) 1506300800 E) DUE TO REPAIRING RWY 09 (REF A0011/15 NOTAMN), IAC VOR/DME RWY09 AND IAC RNAV (GNSS) RWY09 CHARTS ARE CHANGED: FOR IAC VOR/DME 09: -FAF DISTANCE FROM ZVR 12.5KM CHANGED TO 11KM. -ON CHART TABLE ALT ARE CHANGED DEPENDING ON FINAL APPROACH DISTANCES. ZVR DME11-5100', ZVR DME9-4747', ZVR DME7-4402', ZVR DME5-4056', ZVR DME3-3711', ZVR DME1-3366' FOR IAC RNAV (GNSS) RWY09: FAF AND THR (MAPT) COORD ARE CHANGED -FAF NEW COORD 400846.79N 0441412.49E -THR (MAPT) NEW COORD 400850.07N 0442325.11E)

There was a lined threshold sign marking with elevated lights on the displaced threshold with

ended white chevrons on beginning of RWY 09.

9

On the beginning of the displaced area, there was a row of elevated lights which used as

approach lights. In this area, the edge line of RWY before displaced threshold was covered

by black color. While displacing of this runway, closed marking signs in displaced area could

help pilot to distinguish more about displaced area.

10

1.11Flight Recorders: This aircraft has been equipped with DFDR and CVR. At the place of incident , the CB of

CVR system was pulled out and aircraft dispatched based on MEL . The DFDR was picked

up from relatively undamaged compartment of aircraft in a very good condition in IKA

airport and presented to Mahan Air Flight Data Monitoring Shop in order to download

/analysis. Also according to request of French Authority (BEA) as the state of manufacturer,

the Row Data File of DFDR was sent to BEA for further investigation.

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1.11.1 Cockpit Voice Recorder:

Made: FAIRCHILD Type: SSCVR

Type Number: 2100-1020-02 Serial number: 00214403

Condition of the Recorder was serviceable with no damaged .The operation of the CVR

recording was not stopped by the pilots, while this incident has happened, so far more than 2

hrs the CVR was engaged and the recorded cockpit voices at the time of incident were lost.

1.11.2 Flight Data Recorder:

Condition of the Recorder: no damaged, serviceable.

Made: Honeywell Type: SSFDR

Type Number: 980-4700-042 Serial number: 6634

The download of the FDR was successful .The initial evaluation of the flight data revealed

known aircraft configuration.

1.11.3 Flight Data Recorder findings:

The following data are a sequence of events based on FDR data. Time references are based

on recorded GMT time of the FDR.

Approach sequences:

Just before reaching the FAF, the aircraft was leveled at 5100 ft QNH with:

AP1 and both FDs engaged in ALT/HDG modes

A/THR engaged in SPEED mode

GW=129T ≤ MLW (= 138T)

Recorded Baro setting : 1018hPa on CPT side, 1017hPa on F/O side

The whole analyzed useful parameters are descripted as:

Notes

FDR information Time(GMT)

AP1 disconnection R.ALT = 630ft AP1 Off 05:42:14

The pilot put off Auto throttle.

Press ALT=2864 ft R.ALT=50 ft

Gear =down CAS=134

A/THR MAN THROTTLE

05:43:37

Aircraft was ready to land

Press ALT=2851 ft R.ALT=43 ft

Gear =down CAS=134

NAVLat = 40.14694 NAVLong = 44.36846

05:43:39

Aircraft was ready to land

Press ALT=2823 ft R.ALT=18 ft

Gear =down CAS=134

NAVLat=40.14694

NAVLong=44.38562

05:43:42

LH-RH Gear touched the RWY

Press ALT=2800ft R.ALT= 0 ft

ML/G Gear Compressed CAS=130

Acceleration = 1.21

05:43:48

Both Engine thrust reversers

were activated

Press ALT=2800ft CAS=117

Eng1 N1 =53→74 , Eng2 N1 =47→64 05:43:53

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1.11.4 Flight path computation:

Distance to the displaced threshold was computed from positions recorded in the FDR.

Positions were corrected so that the aircraft Main L/G position at the time of touch down is

before displaced threshold.

A vertical flight path was computed from recorded pressure altitude and distance to the

displaced threshold. On the following plot, FDR altitude values were corrected with QNH

1018 and levelled to 2800 ft when recorded below 2800 ft.

The flight path is compared to the approach path described in the NOTAM and the approach

path of the approach chart (dashed line).

The flight safety office of the Airbus Co. also performed a vertical flight path computation

which has similar results.

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1.12 Wreckage and Impact Information:

After landing of aircraft in the destination (EVN), the visual inspection was made on the

aircraft and RWY threshold with these results:

There was not any deflection on the airframe and control surfaces.

There are signs of impact of elevated threshold light on the main gear tire.

1.13 Medical and Pathological Information:

The Alcohol tests were done for both pilot and co-pilot by request of Armenian Authority

immediately after the incident and the result analysis was Negative.

1.14 Fire:

No fire occurred for the aircraft.

1.15 Survival Aspects:

Nobody was injured in this incident, so survival aspects are not considered.

1.16 Tests and Research:

The raw data of FDR was sent to the BEA/ France for read out. The read out of FDR

parameters had some differences from FDM of the Operator, so some corrections of available

data were made.

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1.17 Organizational and Management Information:

Mahan Air is an Iranian private airline that offers passenger and cargo services, including

domestic and international flights. The company’s corporate office is in Mahan Air Tower,

Azadegan St., Karaj Highway, Tehran. This Airline operates a fleet of more wide body

airplanes, consisting of Airbus 300s, 310s, 340s; Boeing 747s and BAe-146s.

1.18 Additional Information:

The pilot used “JEPPESEN “approach chart available in his IPAD for flying to the EVN

airport and no difference was detected with Armenian AIP.

1.19 Useful or Effective Investigation Techniques: The standard and normal techniques were applied.

2. ANALYSIS:

On 17 May 2015, at the morning time of the day both pilots were attended in Dispatch

office of Mahan Air in Imam Khomeini Airport (IKA)/Tehran. The dispatcher delivered

flight document bag to the pilot without concentration about EVN NOTAM. The crew

briefing has been done in the dispatch but the pilot did not pay attention to the available

NOTAM in flight documents so far coordination between him and his first officer was not

done.

The aircraft took off from RWY 29 R IKA (Imam Khomeini) airport destination to EVN

(Yerevan) as a scheduled flight. On the whole time of flight the pilot-in-command on left

cockpit seat was the Pilot Flying (PF). The cruise flight level was FL340 and the flight has

entered Yerevan FIR via point MAGRI.

Subsequently, the Yerevan ACC controller informed the pilot about radar vectoring for

VOR/DME RWY09 for the approach and acknowledged by the pilot. Based on listening to

ATIS, the copilot request about the serviceability of ILS, the controller advised that: "ILS

Unserviceable".

Then the aircraft was cleared to perform approach. The pilots didn’t have enough

information about NOTAM while performing initial briefing. The flight was requested to

descend to FL160 and delivered to the approach controller for further descent. When the

aircraft was under the control of APP RDR unit, according NOTAM A001/15 the pilot was

informed of the displacement of threshold RWY09 by 1450m to the aerodrome reference

point by APP controller.

15

Then, the flight was vectored to descend to 5100ft for VOR/DME for RWY09. According

to mentioned NOTAM the final approach fix point (FAF) position displaced about 1.5 KM

near to the RWR 09 of EVN airport.

FOR IAC VOR/DME 09: -FAF DISTANCE FROM ZVR 12.5KM CHANGED TO 11KM.

With this correction, the flight should be level off from 5100 feet about 7 DME from the

threshold but the pilot began it from 8 DME according to JEPPESEN available approach

chart in his IPAD and the text of NOTAM was not considered by the pilot so he made

VOR/DME approach chart for RWY 09 based on uncorrected chart. While the pilots were

informed about displaced runway , the pilot decided to continue flight at visual approach and

use maximum length of the shorten runway so the flight path shows below glide path. Since

provided NOTAM have not been read completely by the cockpit crew, so they were not fully

informed about the situation mentioned in the NOTAM

AT 05:40:55 about 6 miles on final, the flight was cleared to land by the tower controller.

At 05:42:00 and elevation of about 3500 ft., the pilot was advised by TWR controller that

A/C is well below and the flight replied that we are approaching visual with sign of new

threshold insight. So far the pilot decreased the rate of aircraft descend and observed

continues of the flight via visual condition.

The pilot did not recognize the temporary approach elevated lights so his concentration was

on threshold elevated lights .Finally at 05:43:48 the aircraft has landed just before threshold

of RWY 09. The touch points of MLG wheels were just before threshold and the touch points

of NLG wheels were after threshold so aircraft main wheels have collided with RWY

thresholds lights during landing on the ground. Then the aircraft vacated the RWY via

taxiway C. Visual inspection by aerodrome safety personnel has indicated that the A/C

landed just before displaced threshold.

Although considering those mentioned matters for the real root cause of the incident; there

were not enough closed marking signs before threshold lights to prevent landing in this

unauthorized displaced area according standard criteria in Annex14. It was recommended in

annex 14 that:

7.1.1 A closed marking shall be displayed on a runway or taxiway or portion thereof which is permanently

closed to the use of all aircraft.

7.1.2 Recommendation.— A closed marking should be displayed on a temporarily closed runway or taxiway

or portion thereof, except that such marking may be omitted when the closing is of short duration and adequate

warning by air traffic services is provided.

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3. CONCLUSIONS:

3.1. Findings:

- Lack of pilot attention to the available NOTM in flight documents.

- Lack of briefing between flight dispatcher and flight crew before departure about

NOTAM.

- Noncompliance of cockpit crew to controller advice.

- If The Closed marking before runway threshold of EVN airport was observed, it could

help the pilot to distinguish displaced area more.

3.2 Main Cause:

The main cause of this incident was “Human Error” of the pilot to review required flight

documents before flight to prepare condition of flight for the destination .

3.3 Contributive Factors:

- Human error of the dispatcher for enough crew briefing

- Lack of attention of the copilot to warn the pilot about displaced area

4. SAFETY RECOMMENDATIONS:

The safety & accident investigation Department of I.R of ran Civil Aviation

Organization issues the following recommendations:

- Mahan Air should investigate those irregularities identified in this report.

- Mahan Air should analyze the Flight Rules and AIP for consistency with the

ICAO regulations in the Procedures for Air Navigation Services - Aircraft

Operations (PANS-OPS –Doc 8168 OPS/611) as to visual maneuvering

during approach to land. To eliminate the identified inconsistencies.

- Mahan Air should consider revising and, if necessary, amending or

supplementing Flight Operation Instructions for other aerodromes and

FOMs for any designated airports.

- Mahan Air should consider revising operation procedure to confirm of

crew briefing in the Dispatch an flights

- The General Civil Aviation Authority of Armenia should concern about

findings of this report to make better supervision to the airports in the

country to reach high levels of safety.